Ebola in Conflict-Affected Areas

As of November 6, the Democratic Republic of the Congo (DRC) Ministry of Health has reported 308 confirmed or probable cases of Ebola, including 156 deaths, in the current outbreak, mostly in the highly populated North Kivu and Ituri provinces. Another 39 suspected cases are being investigated as well. This Ebola outbreak is already among the three largest in DRC history; however, if not brought under control quickly, it is poised to become one of the largest across all countries.

Ongoing Response Activities and Challenges

As we reported in a previous Outbreak Thursday post, the current Ebola outbreak is particularly concerning because of the unstable security situation resulting from ongoing active conflict in the area, which is inhibiting public health surveillance and response efforts. Currently, more than a million people in the region are displaced, and there is frequent movement of populations to neighboring regions in Uganda, Burundi, and Tanzania. The most recent situation report from the WHO (November 6) noted that more than 16,000 contacts have been registered, and nearly 5,000 remain under surveillance. Responders have been able to follow up with at least 90% of identified contacts; however, a “large proportion” of cases are being diagnosed among people not previously identified as contacts, indicating gaps in current surveillance efforts. Compared to previous outbreaks, investigational vaccines and therapeutics have been made more widely available during this response. Specifically, ring vaccination has been implemented as a containment strategy, resulting in the vaccination of nearly 29,000 individuals. Furthermore, healthcare workers (HCWs) in neighboring countries are also getting vaccinated in preparation for possible spread to their regions.

Despite these concerted efforts by the WHO and other partners, the substantial security risks in the region have hindered measures to control the outbreak. There are increasing reports of medical workers facing attacks and armed groups actively preventing responders from accessing affected villages. During a recent Congressional seminar led by Johns Hopkins Center for Health Security Director Dr. Tom Inglesby, US CDC Director Dr. Robert Redfield discussed some of the present challenges affecting response efforts and the risks associated with responders’ inability to perform response activities.

Prior Outbreaks Experienced Similar Challenges

While this current outbreak is the first to occur in an active conflict zone, it is not the first time that Ebola has spread in regions with security issues. These previous responses have illustrated mechanisms to control Ebola outbreaks in the face of similar circumstances. For example, the 2000-01 Ebola outbreak in the Gulu district of Uganda—the second largest in history, with 425 cases and 224 deaths—came at a time when Uganda was recovering from decades of conflict. The initial outbreak was first identified when clusters of funeral attendees and HCWs became ill. The index case was never identified, but it was suspected that the movement of populations across Uganda’s borders with Sudan [NOTE: this area is now South Sudan] and DRC facilitated the importation of Ebola. There was also speculation that members of Sudanese or Ugandan forces brought the disease to Gulu, but this was never confirmed. Control activities included active surveillance and contact tracing among cases. Additionally, health officials established safe burial teams, temporarily banned large community gatherings, and conducted education efforts. In particular, the communication strategies utilized in the response were cited as crucial. Media sources regularly educated the public, generally using messaging that helped reduce fear and misinformation, and twice-daily media briefings also helped information sources keep abreast with the most current developments.

Nevertheless, substantial security issues and challenges existed, many of which are present in the current DRC outbreak. Armed military escorts traveled with medical response teams at risk of attacks from rebel groups. Supply shortages were common, and some HCWs became infected due to inadequate infection control measures. Delays among community members in adopting safe burial practices and other protective behaviors also contributed to the outbreak’s initial spread, and there was a significant lack of trust among the local population and response personnel, fueled by long-standing distrust in the Ugandan government. Additionally, despite education efforts, rumors spread about the response that inhibited outbreak control. In spite of these difficulties, response efforts were successful in controlling the outbreak. One major difference between this outbreak and the current outbreak in DRC is that there is some evidence that rebel groups supported some response activities, which likely helped bring the outbreak under control.

A 1995 outbreak in Kikwit, Zaire [NOTE: this area is now DRC] also posed similar types of challenges, though active conflict was not as present at the time. Affecting 317 people and killing 245 individuals, the nosocomial Ebola outbreak was the second largest in DRC history, and similar to today, occurred during a time of tumultuous political issues. Public health challenges included weakened health systems, decreased willingness among HCWs to provide patient care, and insufficient surveillance. Health officials implemented effective citywide passive surveillance at health centers as well as active surveillance conducted by medical students. Additionally, a rumor registry was established for documenting suspected cases and deaths. Catholic missions in Kikwit used shortwave radio systems to inform local response personnel of potential case patients and affected villages. Protestant missions and members of the public with radios also contacted responders when necessary. All bodies were buried by Red Cross volunteers, ensuring safe burials.

Moving Forward

Past Ebola responses were able to successfully control the outbreak despite security issues. Although the current situation in an active conflict area is more severe than of those in the past, the challenges faced in the three outbreaks are similar. The current outbreak response already involves many of the measures taken previously, including surveillance, contact tracing, and education efforts; however, response measures are being hindered by the security situation, substantially limiting their impact. Providing the necessary support to responders so they can safely and effectively implement the response activities we know to be effective is critical for preventing this outbreak from getting substantially worse.

Photo: Responders don PPE before responding to a reported Ebola death in a village in 2012. Photo courtesy of CDC.

Outbreak Observatory aims to collect information on challenges and solutions associated with outbreak response and share it broadly to allow others to learn from these experiences in order to improve global outbreak response capabilities.